gastro Flashcards
investigations for diverticular disease
FBC → ↑WCC, ↑CRP, microcytic anaemia
Erect CXR → exclude pneumoperitoneum caused by perforation
Barium enema → sawtooth appearance of lumen (investigation of choice)
USS → assess bowel wall thickness, rule out other differentials
CT abdomen
Colonoscopy
indications for end ileostomy
permanent: panproctocolectomy for UC or FAP
temporary: emergency bowel resection for intra-abdominal sepsis, haemorrhage
indications for end colostomy
permanent: abdominoperineal resection for cancer involving anal sphincter
temporary: Hartmann’s (diverticulitis / bowel obstruction from cancer)
Hartmann’s procedure definition + indications
proctosigmoidectomy (rectosigmoid resection) → temporary end colostomy
emergency surgery when immediate anastomosis not possible for:
• Inflammation e.g. diverticulitis
• Colorectal cancer → obstruction / perforation
causes of abdominal distension
fat fluid: ascites fetus flatus: IBS, bowel obstruction faeces
causes of small bowel obstruction
adhesions
hernia
intra-abdominal masses e.g. lymphoma
causes of large bowel obstruction
colorectal cancer
volvulus
strictures e.g. from diverticular disease
bowel obstruction management
ABCDE
drip + suck (NBM + NGT decompression + IV fluids)
analgesia
definitive:
SBO → gastrograffin follow-through
laparotomy → bowel resection if: no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
indications for laparotomy in bowel obstruction
no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
SMA supplies which parts of bowel?
distal duodenum → splenic flexure
IMA supplies which parts of bowel?
splenic flexure → rectum
indications for loop ileostomy
anterior resection (rectosigmoid resection) + anastomosis for colon cancer / Crohn’s
indications for loop colostomy
relief of Sx of obstruction (no resection)
rare
Kocher’s incision: where + for what surg
L subcostal → open cholecystectomy
R subcostal → splenectomy / distal pancreatectomy
McBurney’s / Gridiron incision: where + for what surg
RIF (2/3 between umbilicus + ASIS) → open appendicectomy
indications for midline laparotomy
emergency: Hartmann’s (obstruction, perforation, trauma), ruptured AAA
elective: colectomy, vascular bypass, AAA repair
Mercedes Benz incision: where + for what surg
subcostal margins + midline → hepatobiliary surgery: liver transplant/resection, Whipple procedure (pancreatic cancer)
rooftop incision: where + for what surg
subcostal margins (similar to mercedes benz but w/o midline) → upper GI surg: oesophagectomy, gastrectomy
Rutherford Morrison / hockey stick / J-shaped incision: where + for what surg
LIF / RIF (more commonly L) → renal transplant
Pfannenstiel incision: where + for what surg
low transverse incision → gynaecological procedures: C-sections / lower urinary tract procedures: radical cystectomy / prostatectomy
flank incision for what surg
nephrectomy: renal cell carcinoma, PKD
inguinal incision for what surg
hernia repair
vertical incision = for vascular access
Lanz incision: where + for what surg
transverse @ McBurney’s point → open appendicectomy (reduced scarring)
stoma complications
immediate: operative complications (pain, infection, bleeding)
early: high output stoma, retraction, ischaemia/necrosis, parastomal abscess
late: parastomal hernia, prolapse, obstruction (strictures / stenosis)
causes of ascites
high albumin gradient (>11g/L): cirrhosis, portal HTN, cardiac failure
low albumin gradient (<11g/L): infection (peritonitis, TB), inflammation (nephrotic syn, pancreatitis), malignancy
causes of hepatomegaly
cirrhosis
malignancy: primary / mets
congestion: cardiac failure, constrictive pericarditis
infection: hepatitis
haematological: leukaemia, lymphoma, myeloproliferative disorders (sickle cell, myelofibrosis)
infiltration: sarcoidosis, amyloidosis, haemochromatosis
anterior resection: definition, indications, results in?
rectosigmoid resection
can be low or high
for rectal cancer not involving rectal sphincter
anorectal anastomosis (if healthy rectum) / temporary loop ileostomy / end colostomy
abdominoperineal resection: definition, indications, results in?
resection of sigmoid + rectum + anal sphincter
for malignancy involving anal sphincter
permanent end colostomy
panproctocolectomy: definition, indications, results in?
resection of entire colon + rectum
for UC / FAP
permanent end ileostomy / J pouch
complications IBD
toxic megacolon
malabsorption → gallstones, vit B12 deficiency
fistula, abcesses, strictures
malignancy: colon / PSC → cholangiocarcinoma
extra-abdominal signs IBD
derm: pyoderma gangrenosum, erythema nodosum, clubbing
eye: iritis, conjunctivitis
hepato-pancreato-biliary: gallstones, PSC → cholangiocarcinoma
histology in UC vs Crohn’s
ulcerative colitis: crypt abscesses
crohn’s: non-caesating granulomas
definition fistula
abnormal connection between two epithelial surfaces
definition hernia
protrusion of viscous / part of viscous through defect of its containing cavity into an abnormal position
indirect vs direct inguinal hernias
direct (20%) via Hesselbach’s triangle (weakness in posterior wall of inguinal canal)
↑intra-abdominal pressure
indirect (80%): through deep ring and out through superficial
patent processus vaginalis
complications more common
more difficult to reduce
differentiate: occlude deep ring + ask patient to cough
induction of remission ulcerative colitis
mild-mod: proctitis / proctosigmoiditis: rectal 5ASA after 4wks: + oral 5-ASA then add oral / rectal corticosteroid extensive: rectal 5ASA + oral 5ASA severe: admission IV corticosteroids \+ ciclosporin / consider surg
causes chronic liver disease
alcohol non-alcoholic fatty liver disease infection: hepatitis autoimmune: hepatitis, PSC, PBC vascular: Budd-Chiari, infiltrative: sarcoidosis, amyloidosis, haemochromatosis
causes of portal HTN
pre-hepatic: portal / splenic vein thrombosis
external compression (malignancy)
hepatic: cirrhosis (most common)
post-hepatic: budd-chiari, congestive heart failure, constrictive pericarditis
presentation portal HTN
ascites splenomegaly oesophageal varices (melaena, haematemesis) caput medusae worsening of haemorrhoids
management oesophageal varices
ABCDE IV fluids terlipressin (reduces portal pressure) endoscopic band ligation can treat portal HTN with TIPS (transjugular intrahepatic portosystemic shunt): hepatic to portal vein
management ascites
monitor weight
diuretics: spironolactone (+ furosemide if required)
fluid + salt restriction
therapeutic paracentesis (+ albumin infusion for large volume paracentesis)
TIPS (transjugular intrahepatic portosystemic shunt) for portal HTN
causes of splenomegaly
portal HTN
haem: leukaemia, lymphoma, myelofibrosis, haemolytic anaemia, sickle cell
infection: TB, malaria, HIV
inflammatory: Felty’s
definition + causes of massive splenomegaly
reaches midline / iliac crest / > 1500g CML myelofibrosis leishmaniasis malaria EBV